Cool Technology of the Week

I've written about the challenges of Spam filtering - false positives and false negatives.

Recently we've experienced a doubling of the volume of incoming Spam. It's essentially a "Spam Denial of Service attack" that is overwhelming our Spam filters. The filters have a failsafe behavior that automatically lets Spam through if the servers get overwhelmed. Leaks of Spam and the increasing challenge of providing reliable, secure, 99% spam free email has caused us to revisit our email configuration and spam filtering products.

Our Spam filtering company, Symantec, provided onsite engineers to examine our configuration and hardware design. They suggested reconfiguration, enhancement of our CPU capacity and an upgrade to the latest software version that "learns" about common email patterns within the organization and whitelists selected traffic, relieving the burden on the spam filtering servers. Symantec also suggested replacing our software-based product with their 8300 series appliance. The appliance is better equipped to process large volumes of mail.

As a class of technologies, Spam filters include pattern recognition, Bayesian probabilistic decisionmaking, and neural network techniques among others. The best comparison of Spam flters, I've found is a recent Infoworld article.

The article illustrates the difficulty in improving our situation. The Symantec product comes out best in class, but only stops 96.4% of Spam. There were products that did better, but most had offsetting problems with false positives. Only Sendio and Proofpoint had better Spam blocking rates and no "critical" false positives. They both had much higher "bulk email" false positives than Symantec which accounted for the "best in class" rating for Symantec. The Infoworld evaluation was based on the Symantec appliance. The appliance has the same anti-spam engine as their software, but can perform additional functions e.g. better reporting, smtp-based throttling based on locally observed reputation, and others. We are testing the appliance now.

Our challenge is that as a healthcare provider, we cannot have false positives. A critical patient email, lab notification, or followup from a medical colleague must be delivered. We will accept a bit more Spam in order to have few false positives.

Thus, for now, we've concluded that an appropriately configured, hardware optimized Symantec configuration is our best bet. The war against Spam is a continuous battle, but for now, 96.4% filtering with very few false positives, wins the race. Hence, Symantec Anti-Spam (formerly known as Brightmail) and their 8300 series appliance is my candidate for the Cool Technology of the Week. Spam is an elusive target, so we'll continue to watch the efficacy of all the available products.

The Tradition of Coining

Last Friday, I delivered the C. Everett Koop lecture at Dartmouth and after the lecture, Dr. Koop shook my hand and passed me a coin in his palm. The coin, pictured above, contains his official 3 Star Vice Admiral insignia as Surgeon General of the US. I thanked him for his support of healthcare IT and one of the Dartmouth professors explained the tradition of coining:

During World War I, American volunteers from all parts of the country joined newly formed flying squadrons in France. One of the lieutenants ordered bronze medallions struck. These medallions carried the squadron emblem and were given out to all squadron members.

On a flight shortly thereafter, the lieutenant's plane was downed behind German lines and he was immediately captured. The Germans took all of his personal identification except for the bronze medallion which he wore in a small leather pouch around his neck. He was taken to a small town near the front. Bombardment was heavy that night, he escaped his captors, but without his identification. He made his way to the front lines avoiding German patrols. Eventually, he managed to find a French outpost. Unfortunately for him, the French in that area had been plagued by sabotage. The French were ready to execute him as a spy when he remembered the leather pouch containing the medallion. He showed the medallion to them and they recognized the squadron insignia on it. His medallion bought him enough time to confirm his identity. Now instead of shooting the young lieutenant, they gave him a bottle of wine.

When he was returned to his squadron and his companions heard his story, it became a tradition to ensure that all members carried their medallion at all times. To ensure that each member carried their coins, they instituted the "challenge". A challenger would ask to see your coin. If you couldn't produce your coin, you were required to buy a drink, but if you produced your coin, the challenging member was required to pay for both your drinks.

The coin is a unique way of recognizing service and building camaraderie.

Dr. Koop is an amazing guy. He's 91 years old and is still a very active academician and public servant. I really appreciated his introduction of me at Dartmouth. He said that if I had never been born, the earth would have continued to turn, however, there's a chance it may have turned a bit more slowly. I'm honored and will proudly carry his coin.

Management Lessons Learned As a Parent

My daughter, Lara Halamka, is 15 years old. Being a parent has taught me more about leadership and management than any of the Spencer Johnson or Peter Drucker books. I've learned patience, communication and the ability to trust.

Here are my top 10 management lessons learned from being a parent:

1. Yelling never has a positive outcome - In my life as a parent, I've raised my voice twice over the past decade and a half. My daughter can remember both times, even though they occurred in the distant past. My outbursts diminished me and had no positive impact on her behavior. In business, if I ever feel that raising my voice would win the battle, I reflect on my life as a parent and hold back, since I know that confrontation ultimately makes the situation worse. As I've said before, "save as draft".

2. Formal authority rarely works - As a CIO, I would never stand in front of group of stakeholders and say "you must do this, because I'm the CIO." Standing in front of a teenager and saying "you must do this, because I'm your father" is just as problematic. Leadership comes from thoughtful discussion, weighing pro's and con's, then ultimately arriving at a consensus. Shared decision making between parents and children based on a fair, consistent, and predictable process preserves domestic tranquility. IT governance preserves organizational tranquility in the same way.

3. Give permission to make mistakes - Wellesley and the surrounding western suburbs of Boston have had a number of teen suicides over the past few years. Parents apply such pressure to perform that many teens have irrational expectations of perfection for themselves i.e. "you can be valedictorian, captain of the squash team, and a Pulitzer Prize winner by the time you're 18". Making mistakes and learning along the way is the way we learn as children and the way we learn as leaders. In management, I find that setting limits, then offering staff the flexibility to excel on their own is far more effective than micro-management and a constant threat of management retribution.

4. Communication is key - During a teenager's development, Mom and Dad may not be perceived as cool, smart, or fun to be with, but this can change by the day. Keeping the channels of communication open as moods change is key. There will be disagreements, but it's less important to win the argument than to ensure you're still speaking when the discussion is over. The same thing is true with customers and employees - I'd rather hear from them about bad news and fix the problem than not hear anything at all.

5. Get the basics right - Why was religion invented? There are encyclopedias written about that topic, but in my opinion, religion was invented to provide a moral/behavioral framework that puts boundaries on human instincts to compete, reproduce, and survive. We do not have a religious household, but we have a moral household. As a parent, I've tried to be a living example that the nice guy can finish first, that theft and aggressive behavior are wrong, and that kindness and consensus win the day. If my examples lead my daughter to make the right choices when faced with tough decisions, then the basic moral framework we've built will be a foundation for her success. In business, setting a tone of expected behavior by being a living example of ethical, fair, and collaborative behavior spreads to staff and customers.

6. You can criticize ideas but do not criticize people - As the brain matures, sensory input is integrated with experience to produce more robust decision making. During that process there will be many experiments, trial/error, and fine tuning. If my daughter makes a decision that I do not agree with, we can debate her ideas but not her abilities. The same is true with employees and customers. I treat everyone with respect even if I do not agree with their ideas.

7. Build a joy of success rather than fear a failure - When I was teen and took the SATs, I had no real knowledge of their importance, I arrived a bit late, and did not stress over the outcome. The result was a scholarship, not because I was smarter than my peers, but because I did not have a fear of failure during the exam. I watch many parents link performance on every test to an admission or rejection from Harvard. Admission to an Ivy League school is equated to happiness. With Lara, we've tried to celebrate success and build a joy of achievement rather than a fear of failure. Thus far, the motivation from within to do well seems much more sustainable than fear of failure for imposed by authority figures. Emphasizing growth and achievement among employees creates a higher performance organization than management by intimidation.

8. Delegate responsibility but emphasize accountability - My daughter tends to have the same sleep cycle that I do, often sleeping 4 or 5 hours a night. Her schedule is left up to her to decide, but when the 6:30am alarm sounds, she is accountable for her decision to go to bed late. Rather than enforce a bedtime and wake time, delegating her sleeping hours to her, but holding her accountable for getting to school on time, awake and alert, has enhanced her decision making. Leadership is the work of worry and it's important to learn accountability early. The more responsibility I'm given, the greater the accountability.

9. Respect innovation - As vegans, my wife, daughter and I grow beets, carrots, turnips each year. Last year, when we picked a bucket of carrots, I recommended to my daughter that we use a sieve to wash off the dirt. She had a different idea of laying them out in the driveway and washing them off with a sprayer. I suggested that sieves have always been used and it's the "right way". Her method, although non-standard, was fast, effective, and efficient. Just because business as usual has always worked, there may be better ways. As I tell my staff - If I become the obstacle to innovation, it's time for me to move on.

10. Accept that the best lessons learned come from independence - For my daughter to develop self esteem, assertiveness, and a willingness to take acceptable risks, she needs to make decisions on her own, even if they are imperfect. If I make decisions for her, she'll be less prepared for life in college and beyond when I may not be present. I give her the best guidance that I can, hope that she develops a strong internal compass, and then let her change from within as she experiences the world. Developing the next generation of leaders in an organization requires the same approach.

I highly recommend parenting over an MBA. Parenthood teaches humility, selflessness, and self-control. No matter what I do in IT, my daughter will be my greatest legacy.

The Journey Towards Electronic Clinical Documentation

Over the past 3 years, we've been executing our Clinical Systems strategic plan to enhance clinical documentation, decision support, and data integration for all our care areas. Each of these deserves its own blog entry, and here's an overview of our clinical documentation efforts.

Outpatient
Over the past 5 years, we've used our self-built, web-based Online Medical Record, called webOMR for ambulatory care automation. By June 30, 2008, all outpatient clinical documentation must be done in webOMR to comply with medical staff bylaws as amended by the Medical Executive Committee. For those areas which require scanning of drawings, we're implementing an outpatient documentation scanning application using Fujitsu scanners and Captiva software, beginning in May.

Emergency Department
Our ED Dashboard is the workflow tool which drives all aspects of patient tracking and results display for the department. We're adding complete electronic documentation to this dashboard by this Summer through a combination templates/macros, structured forms and free text typing.

Anesthesia/ORs
We've installed the Philips Compurecord Intraoperative charting application which includes automated interfaces to anesthesia machines, labs and all OR telemetry.

ICUs
We've installed the iMDSoft Metavision charting application which includes automated interfaces to all ICU monitors, labs, and ventilators. We worked with iMDSoft to implement highly structured documentation which makes rounding and charting more accurate and efficient.

PACU
We're studying the right solution for the PACU now and we may implement iMDSoft there, ensuring one patient charting system is used for all perioperative management.

Ward Beds
We have a very comprehensive self-built Online Medical Record for all ambulatory encounters and we're enhancing it to support all clinical documentation on the wards. Here's the step by step implementation plan:

2007 - We implemented scanning of existing paper charts to provide a means of retiring our dependence on paper for medical record coding and historical review

2008 - By June, we'll go live with electronic History and Physicals which include a medication reconciliation function that is tightly linked to the outpatient record. The latter ensures medications will be tracked accurately as patients transition between inpatient and outpatient settings of care.

2009 - We'll expand our automated history and physicals charting applications to support daily inpatient progress notes. Once this is complete, we'll be able to integrate our self-built team census application with electronic charting to automate all signout processes. Automated signout processes will provide a means to document the responsible caregiver for the patient at all times.

2010 - Once all aspects of charting, signout, historical and physicals, operative notes, etc. are completed, we'll be able to create a highly detailed automated discharge summary. Today, we have a discharge document that is sent via the MA-Share infrastructure to the next provider of care and includes meds/problems/followup, but our next version will also incorporate all our electronic documentation features for a truly multidisciplinary continuity of care document for each patient.

By 2010, we will have reached the tipping point such that our need for paper documentation will have diminished and we can officially declare the electronic record as the official medical record. Today, we have a hybrid paper/electronic record during our transition state. Step by step we're on a logical journey toward clinical documentation and we're involving many clinicians, the HIM department and our governance committees in all our efforts.

Most Popular Educational Technologies

In 2001, Harvard Medical School went live with the Mycourses educational portal (check it out by clicking on take a tour) , which includes content management, collaboration, and online evaluation for faculty and students.

Here's an overview of the most popular technologies in Mycourses and the reasons they've been popular.

Virtual Microscopy
Remember using a light microscope and the trying to get a clear, focused image while dripping oil on the 1200x lens? Using a microscope is a different skill than learning pathology/histology, so we teach them separately. Students have a few hours of hands on experience with lenses and oil followed by a 100 hours of learning the pathology/histology via Virtual microscopy - streaming, high definition, zoom-able, movable images onto the web using technologies from Aperio and MicroBrightField.

With Virtual Microscopy, faculty navigate tissue sections via the web and project them on an HDTV display or LCD projector, pointing out salient areas on a slide in real-time without the use of a 12 headed microscope or other expensive optical technology previously needed for group work. Faculty digitize rare slides and make them accessible to all students and faculty in a very convenient way for both education and research purposes. From the student’s point of view, slides can be reviewed 24x7 from their dorm room.

Visual Encyclopedias
The web is an ideal vehicle for delivering "new media" that beyond the text based content of traditional textbooks. We've created our own specialized visuals for radiology instruction and visual diagnosis, but we've also licensed two commercial products.

VisualDx, an online visual decision support tool, was developed to assist students and physicians in pattern recognition, diagnosis, and treatment. Unlike traditional atlases or textbooks, VisualDx allows one to enter the patient’s key signs and symptoms (eg, dyspnea, abdominal pain, widespread papules), and in seconds the system generates a patient-relevant differential diagnosis.

Primal Pictures is a 3-D Online Anatomical resource with extremely detailed models of the human body that we've used in the anatomy lab by placing flat screens on mobile mounts above cadavers. The students can navigate three dimensional images, remove virtual tissue layers, and explore the relationships of structures to one another in real time while doing dissection.

Online Procedures and Simulations
Does the bevel go up or down when doing a blood gas? What are the anatomical landmarks when doing a lumber puncture? By making flash and streaming video procedure instruction available via the web and mobile devices, we provide our students with just in time instruction before they do a procedure.

We also use Flash for highly interactive simulation/exploration of difficult to learn concepts. For example, to teach the relationship between heart sounds, PA catheter tracings, EKG, and Pressure-Volume loop, we've used flash. We have 200 of these simulations for all aspects of human physiology.

Collaboration tools
We've implemented centralized shared storage for individuals and ad hoc collaborations which enable any groups to exchange files and set file read/write/delete attributes for every participant.

For real time group collaboration, we've deployed Webex and Elluminate. Although we do have video teleconferencing facilities available, we've found that audio conference calls combined with real time presentation tools are the most effective way to deliver real time educational materials to collaborative groups.

Streaming videos and podcasting
Our most popular application is streaming video of recorded lectures with over 60,000 views each year. We also podcast all our lectures so that students can replay lectures on their ipods. We use Apreso for combining lecture slides and videos, Streamsage for full text indexing of spoken words, and Real Server/Player for routine video delivery. One of the most popular features is Enounce Time Scale Modification of Audio , which enables videos to be watched at twice normal speed with frequency correction so that voices sound normal. Students can watch 8 hours of lectures in 4 hours! It is true that attendance of lectures has diminished since we made streaming video available, but attendance at interactive sessions such as tutorials has stayed the same.

Our next generation of portal will include more social networking features, more opportunities for collaboration among the medical school and hospital affiliates, and support for classrooms of the future which incorporate more real time video collaboration and resource sharing.

It's very clear that the web is empowering entirely new ways to deliver educational material and the way we teach must evolve.

Cool Technology of the Week

I travel about 400,000 miles a year.

I can tolerate the late departures and arrivals, the surly airline staff, and the sardine-like seating arrangements, but the unpredictability of the security screening process is a nightmare. Sometimes I arrive at an airport and jog through the security line in minutes. Many times I arrive to find a security line longer than a football field with an hour long wait, causing me to miss my flight.

Given that I'm a trustworthy traveler who only carries a toothbrush and an extra pair of socks, should I wait in the same line as the once a year traveler with a bag full of liquids/gels, a giant carry on suitcase, and a stroller?

The notion of a "Registered traveler", who is trustworthy and carries non-repudiatable identity credentials makes a great deal of sense.

Clear has implemented a fast pass for airport security with a process and a smart card. It's the Cool Technology of the Week. Clear members are pre-screened via a government approval process and carry an identity card which allows them to access designated airport security "fast lanes" nationwide. In my experience at Orlando, Dulles, Reagan, and San Francisco, Clear members pass through airport security faster, with more predictability.

The smart card contains basic demographic data - name and address, but also contains biometric data including a photograph, height, fingerprints and iris scans.

Enrollment is a two step process - an online application and in person identity verification.

The identity verification is completed at a Clear enrollment station (airports supporting the technology), where a Clear staffer verifies two government issued IDs, takes your picture, captures your iris and fingerprint scan, then submits everything to the government for clearance.

Clear's identity theft policy is well thought out and minimizes the risk to the Clear members if their database or card technology is compromised.

The price is $100 per year plus the TSA vetting fee of $28.

I plan on completing my Clear enrollment on my next flight to Washington DC in May. Once I have the card, I can bypass security lines and go directly to baggage screening.

The number of airports supported Clear is growing, but just the support for the Washington DC and San Francisco airports make it worthwhile for me, since I pass through these dozens of times per year. Making the airport experience a little more predictable is about the best way I can improve my mental health in 2008, so Clear is a definitely cool technology.

The Cosmopolitan Dating Test

Today's blog is about that fine academic journal of all things health and relationships, Cosmopolitan. I do not read Cosmo, but I know several people who have.

I was recently told about groundbreaking Cosmopolitan research that identified the "4 Types of Men You Never Want to Date". I have to publicly admit that I have failed the "Cosmopolitan Dating Test".

Let's take a look at the 4 personality types that Cosmo has declared to be losers:

1. The Adrenaline Junkie - You definitely want to stay away from rock climbers, alpinists, and ice climbers because they will spend so much time on their outdoor adventures that there will never be quiet time for a bowl of popcorn and "Sleepless in Seattle". They'll be planning their next adventure, coiling their ropes, and checking their gear lists. Next thing you'll know they'll want to climb every mountain in New Hampshire.

2. Nice Guy with a Chip on His Shoulder - I am a nice guy, but alas, I have a Chip in my shoulder containing all my medical records. In addition, the Cosmo researchers warn against the guy with stylized dressing habits, definitely ruling out my black Nehru jacket, black shirt, and vegan shoes. Stylish dressers spend so much time thinking about ways to accessorize that they'll never have time for moonlit walks on the beach.

3. Smooth Operator - The guy with the polished anecdotes about life as a CIO, leadership lessons learned, and spellbinding tales of project management will never have time to whisper sweet nothings in your ear.

4. Workaholic Hotshot - Definitely be wary of the guy with an 80 hour work week who has multiple jobs and doesn't sleep much. He'll be so attached to his Blackberry that there will never be a romantic moment away from a keyboard.

My wife and I have been together for 28 years, through sickness and health, Windows and Mac OS, residency and network outages, so I think it will last. When I explained what a loser I am according to Cosmopolitan, her response is that she would never want to date me, just marry me. Aw shucks...